Dozens of clinical commissioning groups are devising innovative contracts in which a lead provider receives an outcomes based payment to integrate an entire care pathway, HSJ can reveal.
The news comes after Bedfordshire CCG on Monday named private company Circle as its preferred bidder to be “prime contractor” for an integrated musculoskeletal service.
If the £120m deal is finalised, Circle − which also runs Hinchingbrooke Health Care Trust − will be financially and clinically accountable to commissioners for the whole pathway. The CCG said this previously involved 20 contracts across primary, secondary and community services.
Bedfordshire is the most advanced CCG in introducing this type of system but HSJ has identified a raft of similar deals in the pipeline.
These include a group of CCGs in Staffordshire planning to commission cancer and end of life care based on outcomes, and Oxfordshire’s proposal to bring in lead providers to integrate maternity, mental health and older people’s services.
Bedfordshire CCG director of strategy and system redesign Diane Gray told HSJ: “About 30-odd CCGs have been in contact with us about the work we are doing here.”
She said they fell into two categories: those considering delivering integrated musculoskeletal services and those interested in outcomes based approaches. It is understood neighbouring Cambridgeshire and Peterborough CCG, which is tendering older people’s services worth £1bn, is among those in contact.
The prime contractor model involves a single organisation subcontracting work to other providers to integrate services across a pathway. A proportion of payments is dependent on the achievement of specific outcomes.
About £4m-£6m of the Bedfordshire contract is dependent on Circle making “game changing” alterations that will improve patient outcomes and service sustainability. HSJ understands the CCG is working informally with consultants to ensure the contract gives it sufficient power over the lead provider.
NHS Partners Network chief executive David Worskett welcomed the model as an “innovative and imaginative” commissioning solution. However, Sir John Oldham, who led a series of integrated care pilots for the Department of Health, said other models could be better suited to some areas of provision.
He said “alliance contracting” − in which a commissioner issues one contract binding several providers − scored highly in the year of care capitation tariff pilots, which looked at people with multiple long term conditions.
Commissioners found this model “created the more cooperative behaviours… in the system” while the prime contractor model risked creating “adversarial” relationships between prime and subcontractors, he added.
Bob Ricketts, NHS England’s director of commissioning support services strategy and market development, said the prime contractor model was “only one tool, but an important one”, and the work in Bedfordshire “could have a huge impact”.
“Bedfordshire is the first example at substantial scale of somebody using outcome based commissioning in a fairly complex area,” he said. “We need to get to a tipping point where we’ve got enough CCGs doing lead provider contracts at scale [so we can] get some serious learning from that, then support and skill up other CCGs to do it.”
Bedfordshire’s decision raises the possibility of private firms winning such contracts. Mr Worskett said: “The private sector has much more experience in joint venturing and partnering. The integrator role could be played by a logisitics company, not a health provider.”
Other senior industry sources told HSJ it was expected many contracts would be won by NHS trust-led consortiums also featuring acute and community providers, GP practices, charities and private firms.